1033608963 NPI number — OAK CITY SPEECH AND LANGUAGE THERAPY, PLLC

Table of content: (NPI 1033608963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033608963 NPI number — OAK CITY SPEECH AND LANGUAGE THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OAK CITY SPEECH AND LANGUAGE THERAPY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1033608963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
105 COOKE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27601-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
919-336-1180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 COOKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27601-1121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-607-6264
Provider Business Practice Location Address Fax Number:
919-336-1180
Provider Enumeration Date:
05/07/2018

Additional Information

Authorized Official

Authorized Official Last Name:
POTTS
Authorized Official First Name:
SHELBY
Authorized Official Middle Name:
GAILE
Authorized Official Title or Position:
SPEECH-LANGUAGE PATHOLOGIST
Authorized Official Telephone Number:
919-607-6264

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  11831 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1326548587 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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